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Ardelean M, Buzas R, Ardelean O, Preda M, Morariu SI, Levai CM, Rosca CI, Lighezan DF, Kundnani NR. Clinical and Biochemical Differences in Patients Having Non-Variceal Upper Gastrointestinal Bleeding on NSAIDs, Oral Anticoagulants, and Antiplatelet Therapy. J Clin Med 2024; 13:5622. [PMID: 39337109 PMCID: PMC11433172 DOI: 10.3390/jcm13185622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Revised: 09/10/2024] [Accepted: 09/15/2024] [Indexed: 09/30/2024] Open
Abstract
Introduction: Upper gastrointestinal bleeding (UGIB) is among the most common causes of morbidity and mortality worldwide, accounting for major resource allocation and increasing incidence. This study aimed to evaluate the severity of non-variceal bleeding in patients at risk of bleeding through the use of NSAIDs, oral anticoagulants, and antiplatelet therapy. Material and Method: The study included 296 patients admitted in the Gastroenterology Department of the Municipal County Emergency University Hospital, Timisoara, between 01.01.2018 and 01.04.2020, and diagnosed via gastroscopy with non-variceal gastrointestinal bleeding. The patients were divided among four groups based on their use of different drugs known to induce UGIB, i.e., aspirin and clopidogrel, NOACs, NSAIDs, and anti-vitamin K drugs, respectively. Statistical analyses were performed based on ANOVA one-way tests for continuous variables and Chi-square tests for categorical variables with pairwise comparisons based on Bonferroni adjusted significance tests. Results: The results showed several parameters having statistical significance among the different groups of patients. Patients on NOACs had statistically significant lower hemoglobin levels, lower hematocrit values, lower erythrocytes, lower RDW and higher fibrinogen levels compared to patients on VKA. Discussion: Surprisingly, the results from our study suggest that the use of NOACs was associated with a higher risk of bleeding when compared to VKA, which differs from the existing literature. Conclusions: One of the important factors causing upper non-variceal bleeding can be iatrogenic, either due to antiplatelet drugs or anticoagulants, to which NSAID treatment is additionally associated for various reasons. In our study, the use of NOACs seemed to have a more severe bleeding spectrum with higher morbidity compared to VKA.
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Affiliation(s)
- Melania Ardelean
- 1st Medical Semiology, Internal Medicine, Department V, Center for Advanced Research in Cardiovascular Pathology and in Hemostaseology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Roxana Buzas
- 1st Medical Semiology, Internal Medicine, Department V, Center for Advanced Research in Cardiovascular Pathology and in Hemostaseology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ovidiu Ardelean
- Second Discipline of Surgical Semiology, Department IX-Surgery-1, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Marius Preda
- Second Discipline of Surgical Semiology, Department IX-Surgery-1, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
- Breast Surgery Research Center, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Stelian Ion Morariu
- Faculty of Medicine, University of Medicine "Vasile Goldis", 310025 Arad, Romania
| | - Codrina Mihaela Levai
- Discipline of Medical Communications, Department II-Microscopic Morphology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ciprian Ilie Rosca
- 1st Medical Semiology, Internal Medicine, Department V, Center for Advanced Research in Cardiovascular Pathology and in Hemostaseology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Daniel Florin Lighezan
- 1st Medical Semiology, Internal Medicine, Department V, Center for Advanced Research in Cardiovascular Pathology and in Hemostaseology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Nilima Rajpal Kundnani
- Discipline of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department VI-Cardiology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Research Centre of Timisoara Institute of Cardiovascular Diseases, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
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Wang XJ, Shi YP, Wang L, Li YN, Xu LJ, Zhang Y, Han S. Clinical characteristics of acute non-varicose upper gastrointestinal bleeding and the effect of endoscopic hemostasis. World J Clin Cases 2024; 12:1597-1605. [PMID: 38576734 PMCID: PMC10989432 DOI: 10.12998/wjcc.v12.i9.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/17/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) constitutes a prevalent emergency within Gastroenterology, encompassing 80%-90% of all gastrointestinal hemorrhage incidents. This condition is distinguished by its abrupt onset, swift progression, and notably elevated mortality rate. AIM To gather clinical data from patients with ANVUGIB at our hospital in order to elucidate the clinical characteristics specific to our institution and analyze the therapeutic effectiveness of endoscopic hemostasis. METHODS We retrospectively retrieved the records of 532 patients diagnosed with ANVUGIB by endoscopy at our hospital between March 2021 and March 2023, utilizing our medical record system. Data pertaining to general patient information, etiological factors, disease outcomes, and other relevant variables were meticulously collected and analyzed. RESULTS Among the 532 patients diagnosed with ANVUGIB, the male-to-female ratio was 2.91:1, with a higher prevalence among males. Notably, 43.6% of patients presented with black stool as their primary complaint, while 27.4% had hematemesis as their initial symptom. Upon admission, 17% of patients exhibited both hematemesis and black stool, while most ANVUGIB patients primarily complained of overt gastrointestinal bleeding. Urgent routine blood examinations at admission revealed that 75.8% of patients had anemia, with 63.4% experiencing moderate to severe anemia, and 1.5% having extremely severe anemia (hemoglobin < 30 g/L). With regard to etiology, 53.2% of patients experienced bleeding without a definitive trigger, 24.2% had a history of using gastric mucosa-irritating medications, 24.2% developed bleeding after alcohol consumption, 2.8% attributed it to improper diet, 1.7% to emotional excitement, and 2.3% to fatigue preceding the bleeding episode. Drug-induced ANVUGIB was more prevalent in the elderly than middle-aged and young individuals, while bleeding due to alcohol consumption showed the opposite trend. Additionally, diet-related bleeding was more common among the young age group compared to the middle-aged group. Gastrointestinal endoscopy identified peptic ulcers as the most frequent cause of ANVUGIB (73.3%), followed by gastrointestinal malignancies (10.9%), acute gastric mucous lesions (9.8%), and androgenic upper gastrointestinal bleeding (1.5%) among inpatients with ANVUGIB. Of the 532 patients with gastrointestinal bleeding, 68 underwent endoscopic hemostasis, resulting in an endoscopic treatment rate of 12.8%, with a high immediate hemostasis success rate of 94.1%. CONCLUSION ANVUGIB patients exhibit diverse characteristics across different age groups, and endoscopic hemostatic treatments have demonstrated remarkable efficacy.
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Affiliation(s)
- Xiao-Juan Wang
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Yu-Peng Shi
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Li Wang
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Ya-Ni Li
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Li-Juan Xu
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Yue Zhang
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
| | - Shuang Han
- Department of Gastroenterology, Honghui Hospital Affiliated to Medicine College of Xi’an Jiaotong University, Xi'an 710054, Shaanxi Province, China
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Vitamin-K Antagonists vs. Direct Oral Anticoagulants on Severity of Upper Gastrointestinal Bleeding: A Retrospective Analysis of Italian and UK Data. J Clin Med 2022; 11:jcm11216382. [PMID: 36362611 PMCID: PMC9656833 DOI: 10.3390/jcm11216382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Gastrointestinal bleeding (GIB) is one of most frequent and significant challenges for emergency physicians and gastroenterologists. Mortality for upper (U) GIB is high, especially in the elderly and comorbid patients. However, there is scant evidence in the literature concerning an assessment of warfarin (VKA) and direct oral anticoagulants (DOACs) in terms of upper gastrointestinal bleeding (UGIB) severity. Aims: Using data from two different settings (Italy and the UK), we aimed to compare the impact of VKA and DOACs on the severity of UGIB. Methods: Retrospective bicentric study on adult patients under VKA or DOACs admitted either to the emergency department at the Gemelli Hospital in Rome, Italy or University College Hospital in London, UK, with suspected UGIB from 01/01/2017 to 31/12/2018. Univariate analysis with Fisher’s exact test, and analysis of variance (ANOVA) were used. Results: 106 patients (62 M/44 F; mean age 71.2 ± 16.9 yrs) were enrolled and divided into the VKA group (N = 57; M: 56%, mean age: 64.9 ± 21.3 yrs) and the DOAC group (N = 49; M: 61%; mean age: 77.6 ± 12.5 yrs). At univariate analysis, the VKA group presented two endoscopic diagnoses more frequently than the DOAC group (26% vs. 8%, p < 0.05), were more frequently endoscopically treated (44% vs. 22%, p < 0.05), rescoped (12% vs. 2%, p = 0.048) and hospitalized (79% vs. 53%, p = 0.01) with a longer length of stay, LOS (VKA: 58% > 5 days vs. DOAC: 68% < 5 days, p = 0.01). There was no difference in terms of hemoglobin level on admission, however the requirement of blood transfusions was higher in the VKA group (60% vs. 41%, p = 0.041). One third of the VKA group showed a lower platelet count than the DOAC group (33% vs. 8%, p = 0.01). No statistically significant differences for in-hospital mortality were observed. For the ANOVA, the type of anticoagulant used was the only significant predictor of need to rescope (p = 0.041) and a significant co-predictor for a LOS > 5 days (p = 0.009; as well as cirrhosis, p = 0.013 and age, p = 0.005). Conclusions: Our outcomes revealed a more severe UGIB in patients on VKA, but the impact of comorbidities (i.e., more cirrhotic patients in the VKA group) cannot be disregarded. DOAC subgroup descriptive analysis, even though on a little cohort, showed higher bleeding severity for rivaroxaban.
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Sung JJY, Moreea S, Dhaliwal H, Moffatt DC, Ragunath K, Ponich T, Barkun AN, Kuipers EJ, Bailey R, Donnellan F, Wagner D, Sanborn K, Lau J. Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding. Gastrointest Endosc 2022; 96:28-35.e1. [PMID: 35124074 DOI: 10.1016/j.gie.2022.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding. METHODS In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality. RESULTS Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods. CONCLUSIONS Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).
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Affiliation(s)
- Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Harinder Dhaliwal
- Department of Medicine, Division of Gastroenterology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dana C Moffatt
- Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Krish Ragunath
- Department of Gastroenterology, NIHR Nottingham Digestive Diseases Biomedical Research Centre, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Terry Ponich
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert Bailey
- Department of Gastroenterology and Hepatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Fergal Donnellan
- Department of Gastroenterology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - David Wagner
- Cook Endoscopy, Winston-Salem, North Carolina, USA
| | - Keith Sanborn
- Cook Research Incorporated, West Lafayette, Indiana, USA
| | - James Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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High- versus low-dose proton pump inhibitors post endoscopic hemostasis in hemodialysis cases with peptic ulcer bleeding. Acta Gastroenterol Belg 2021; 84:3-8. [PMID: 33639687 DOI: 10.51821/84.1.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Post-endoscopic hemostasis treatment is not adequately addressed in high-risk patients on regular hemodialysis (HD) with emergency peptic ulcer bleeding. This study aimed to compare post-endoscopic high- versus low-dose proton pump inhibitors (PPIs) for peptic ulcer bleeding in patients undergoing regular HD. This prospective study comprised 200 patients on regular hemodialysis having emergency peptic ulcer bleeding confirmed at endoscopy and managed with endoscopic hemostasis. Half of the patients received high-dose intensive regimen and the other half received the standard regimen. Patients who were suspected to have recurrent bleeding underwent a second endoscopy for bleeding control. The primary outcome measure was rate of recurrent bleeding during period of hospitalization that was detected through second endoscopy. Rebleeding occurred in 32 patients ; 15 in the High-Dose Cohort and 17 in the Low-Dose Control (p = 0.700). No significant differences between the two dose cohorts regarding the time of rebleeding (p = 0.243), endoscopic hemostasis mode (p = 1.000), and need for surgery (p = 0.306). The highdose regimen Inhospital mortality in high-dose group was 9.0% compared to 8.0% in the low-dose group (p = 0.800). Apart from the pre-hemostatic Forrest classification of ulcers, there were no significant differences between patients with re-bleeding ulcers (n=32) and those with non-rebleeding (n=168). Rebleeding was more common in class Ia, i.e. spurting bleeders (p < 0.001). Endoscopic hemostasis followed by the standard low-dose PPI regimen of 40 mg daily IV boluses is safe and effective option for bleeding peptic ulcers in the high-risk patients under regular hemodialysis.
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Yang H, Pan C, Liu Q, Wang Y, Liu Z, Cao X, Lei J. Correlation between the Glasgow-Blatchford score, shock index, and Forrest classification in patients with peptic ulcer bleeding. Turk J Med Sci 2020; 50:706-712. [PMID: 32041384 PMCID: PMC7379461 DOI: 10.3906/sag-1906-154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 02/09/2020] [Indexed: 12/26/2022] Open
Abstract
Background/aim To investigate the correlation between the Glasgow-Blatchford score, shock index, and Forrest classification in patients with peptic ulcer bleeding (PUB). Materials and methods A total of 955 patients with PUB were assessed using the Glasgow-Blatchford score and shock index, as well as the Forrest classification based on their gastroscopy results. The correlation between the Glasgow-Blatchford score and shock index was determined using scatter plot analysis, and the correlation between the Glasgow-Blatchford score or shock index and Forrest classification was determined using Spearman’s analysis. Results Both the Glasgow-Blatchford score and shock index showed the highest values in patients with Forrest class IIa. The Glasgow-Blatchford score was significantly higher than patients with Forrest class Ib/IIc/III (P < 0.05), and the shock index was significantly higher than patients with Forrest class Ib/IIb/III (P < 0.05). A positive correlation was observed between the Glasgow-Blatchford score and shock index, at r = 0.427 (P < 0.001). A negative correlation was observed between the Glasgow-Blatchford score and Forrest classification, at r = –0.111 (P < 0.01), and between the shock index and Forrest classification, at r = –0.138 (P < 0.01). Conclusion A moderate correlation was observed between the Glasgow-Blatchford score and shock index in patients with PUB, and the correlation between the Forrest classification and Glasgow-Blatchford score or shock index was relatively low.
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Affiliation(s)
- Hong Yang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Chen Pan
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Qi Liu
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yan Wang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zhe Liu
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xian Cao
- Department of Gastroenterology and Hepatobiliary, The Affiliated Baiyun Hospital of Guizhou Medical University, Guiyang, China
| | - Jingjing Lei
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Dinçer D, Ulukal Karancı E, Akın M, Adanır H. NSAID, antiaggregant, and/or anticoagulant-related upper gastrointestinal bleeding: Is there any change in prophylaxis rate after a 10-year period? TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:505-510. [PMID: 31199288 DOI: 10.5152/tjg.2019.19057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/AIMS Using proton-pump inhibitor (PPI) is a protective option for patients who require long-term non-steroidal anti-inflammatory drugs (NSAIDs) and antiaggregants. In our previous study, the rate of PPI use in prophylaxis was found to be 2%. Here we aimed to investigate whether there is a change in PPI use in prophylaxis in a similar patient group after 10 years. MATERIALS AND METHODS The patients who followed up with upper gastrointestinal (GI) bleeding diagnosis between January 01, 2016 and December 31, 2017 were retrospectively evaluated. Patients who had malignancy or variceal hemorrhage were excluded. Ninety-six patients, who had taken NSAIDs, antiaggregants, or anticoagulants that were considered as the possible cause of bleeding, were included in the study. Risk groups for NSAID GI toxicity and PPI use rates in these patients were evaluated. RESULTS Twenty (21%) of all patients with upper GI bleeding were using PPI. According to the pre-bleeding risk factor assessment, 86% of the patients were found to have moderate to high risk for NSAID-related GI bleeding, and 81% of these patients were not using PPI. PPI prophylaxis was not provided to 15 (75%) of the 20 patients with previous history of peptic ulcer bleeding. CONCLUSION Despite many studies and recommendations on risk factors and prophylaxis for NSAID-related bleeding, prophylactic PPI use is still largely ignored by physicians. The rate of PPI use in the patient group of this study was found still quite insufficient.
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Affiliation(s)
- Dinç Dinçer
- Department of Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ece Ulukal Karancı
- Department of Internal Medicine, Akdeniz University School of Medicine, Antalya, Turkey
| | - Mete Akın
- Department of Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Haydar Adanır
- Department of Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
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Only full adherence to proton pump inhibitors protects against drug-induced upper gastrointestinal bleeding. Eur J Clin Pharmacol 2018; 74:1503-1511. [PMID: 30043109 DOI: 10.1007/s00228-018-2523-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The use of gastroprotective agents has allowed significant progress in the prevention of upper gastrointestinal bleeding (UGIB) associated with non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents. Nevertheless, some concerns remain regarding the gastroprotective dosage and treatment duration. Our aim was to study the effect of gastroprotective agents in UGIB induced by NSAIDs and single- or dual-antiplatelet therapy. METHODS A multicenter case-control study was conducted including 577 cases diagnosed with UGIB and 1343 sex-, age-, and hospital-matched controls. To estimate exposure to NSAIDs and gastroprotective agents, consumption was calculated for the 4 weeks prior to hospital admission in terms of defined daily doses (DDDs). Risk groups for UGIB induced by NSAIDs and single- or dual-antiplatelet therapy were defined as a function of each drug dose, use of gastrointestine-damaging drugs, and risk factors for UGIB. Odds ratios (ORs) with 95% confidence intervals (CIs) were adjusted for single- (model 1) and dual- (model 2) antiplatelet therapy. RESULTS Full adherence (> 0.80DDD) to proton pump inhibitors (PPIs) was the only gastroprotective therapy that significantly reduced the risk of UGIB, considering NSAID risk (OR: 0.53; 95% CI: 0.30-0.95) and dose (OR: 0.48; 95% CI: 0.27-0.87) with ORs adjusted for single-antiplatelet therapy (model 1) and NSAID risk (OR: 0.55; 95% CI: 0.31-0.98) and dose (OR: 0.49; 95% CI: 0.28-0.89) with ORs adjusted for dual-antiplatelet therapy (model 2). CONCLUSIONS These results reinforce the recommendation of adding a PPI at effective doses (full adherence) to prevent UGIB induced by NSAIDs, or single- or dual-antiplatelet therapy.
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Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
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Song IJ, Kim HJ, Lee JA, Park JC, Shin SK, Lee SK, Lee YC, Chung H. Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer. J Gastric Cancer 2017; 17:374-383. [PMID: 29302377 PMCID: PMC5746658 DOI: 10.5230/jgc.2017.17.e42] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/16/2022] Open
Abstract
Purpose Bleeding is one of the most serious complications of advanced gastric cancer (AGC) and is associated with a poor prognosis. This study aimed to evaluate the clinical outcomes of endoscopic hemostasis for bleeding in patients with unresectable AGC. Materials and Methods This study included 106 patients with bleeding associated with gastric cancer who had undergone endoscopic hemostasis between January 2010 and December 2013. Clinical characteristics, treatment outcomes, including rates of successful endoscopic hemostasis and rebleeding, risk factors for rebleeding, and overall survival (OS) were investigated. Results Successful initial hemostasis was achieved in 83% of patients. Rebleeding occurred in 28.3% of patients within 30 days. The median OS after initial hemostasis was lower in patients with rebleeding than in those without rebleeding (2.7 and 3.9 months, respectively, P=0.02). There were no significant differences in disease status and rebleeding rates among patients with partial response or stable disease (n=4), progressive disease (n=64), and first diagnosis of disease (n=38). Univariate and multivariate analyses (P=0.038 and 0.034, respectively) revealed that transfusion of ≥5 units of RBCs was a significant risk factor for rebleeding. Conclusions Despite favorable success rates of endoscopic hemostasis for bleeding associated with gastric cancer, the 30-day rebleeding rate was 28.3% and the median OS was significantly lower in patients with rebleeding than in those without rebleeding. Massive transfusion (≥5 units of RBCs) was the only significant risk factor for rebleeding. Patients with bleeding associated with AGC who have undergone massive transfusion should be observed closely following endoscopic hemostasis. Further research on approaches to reduce rebleeding rate and prevent death is needed.
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Affiliation(s)
- In Ji Song
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ju Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Ji Ae Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
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Fujita M, Manabe N, Murao T, Osawa M, Hirai S, Fukushima S, Shogen Y, Nakato R, Ishii M, Matsumoto H, Hata J, Shiotani A. Differences in the clinical course of 516 Japanese patients with upper gastrointestinal bleeding between weekday and weekend admissions. Scand J Gastroenterol 2017; 52:1365-1370. [PMID: 28925290 DOI: 10.1080/00365521.2017.1377762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Patients suspected of having upper gastrointestinal bleeding (UGIB) admitted during the weekend tend to have a poor outcome in western countries. However, no Japanese studies have been reported on this matter. We aimed to evaluate differences in the clinical course of patients with UGIB between weekday and weekend admissions in Japan. METHODS Medical records of patients who had undergone emergency endoscopy for UGIB were retrospectively reviewed. The severity of UGIB was evaluated using the Glasgow-Blatchford (GB) and AIMS65 score. Patients in whom UGIB was stopped and showed improved iron deficiency anemia after admission were considered as having a good clinical course. RESULTS We reviewed 516 consecutive patients and divided them into two groups: Group A (daytime admission on a weekday: 234 patients) and Group B (nighttime or weekend admission: 282 patients). There was no significant difference in GB and AIM65 scores between the Groups. The proportions of patients with good clinical course were not significantly different between groups (A, 67.5% and B, 67.0%; p = .90). However, patients in Group B underwent hemostatic treatments more frequently compared with those in Group A (58.5% vs 47.4%, p = .012). Multivariate analysis showed that taking acid suppressants, no need for blood transfusions, use of hemostatic treatments, and GB score <12 were associated with a good clinical course. CONCLUSIONS There were no significant differences in the clinical outcomes of patients with UGIB admitted during daytime on weekdays and those admitted at nighttime or weekends partly owing to the sufficient performance of endoscopic hemostatic treatments.
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Affiliation(s)
- Minoru Fujita
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Noriaki Manabe
- b Department of Clinical Pathology and Laboratory Medicine, Division of Endoscopy and Ultrasonography , Kawasaki Medical School , Kurashiki , Japan
| | - Takahisa Murao
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Motoyasu Osawa
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Shinsuke Hirai
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Shinya Fukushima
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Yo Shogen
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Rui Nakato
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Manabu Ishii
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Hiroshi Matsumoto
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Jiro Hata
- b Department of Clinical Pathology and Laboratory Medicine, Division of Endoscopy and Ultrasonography , Kawasaki Medical School , Kurashiki , Japan
| | - Akiko Shiotani
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
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12
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Safety, tolerability, pharmacokinetics and pharmacodynamics of dexlansoprazole injection in healthy Chinese subjects. Eur J Clin Pharmacol 2017; 73:547-554. [DOI: 10.1007/s00228-017-2206-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/17/2017] [Indexed: 12/26/2022]
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13
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Kim JS, Ko BS, Son CH, Ahn S, Seo DW, Lee YS, Lee JH, Oh BJ, Lim KS, Kim WY. Can Glasgow-Blatchford Score and Pre-endoscopic Rockall Score Predict the Occurrence of Hypotension in Initially Normotensive Patients with Non-variceal Upper Gastrointestinal Bleeding? THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 67:16-21. [DOI: 10.4166/kjg.2016.67.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Son
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Jin Oh
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Kärkkäinen JM, Miilunpohja S, Rantanen T, Koskela JM, Jyrkkä J, Hartikainen J, Paajanen H. Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2015; 60:3707-15. [PMID: 26177705 DOI: 10.1007/s10620-015-3806-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND No current data are available on rebleeding and mortality risk in patients who use alcohol excessively and are admitted for non-variceal upper gastrointestinal bleeding (NVUGIB). This information could help in planning interventions and follow-up protocols for these patients. AIM This study provides contemporary data on the long-term outcome after first-time NVUGIB in alcohol abusers (AAs) compared to non-abusers (NAs). METHODS Consecutive patients hospitalized for their first acute gastrointestinal bleeding from 2009 through 2011 were retrospectively recorded and categorized as AA or NA. Risk factors for one-year mortality and rebleeding were identified, and patients were further monitored for long-term mortality until 2015. RESULTS Alcohol abuse was identified in 19.7% of patients with NVUGIB (n = 518). The one-year rebleeding rate was 16.7% in AAs versus 9.1% in NAs (P = 0.027). Alcohol abuse was associated with a twofold increase in rebleeding risk (P = 0.025); the risk especially increased 6 months after the initial bleeding. The study groups did not differ significantly in 30-day (6.0%) or one-year mortality rates (20.5%). However, there was a tendency for higher overall mortality in AAs than NAs after adjustment of comorbidities. CONCLUSION AAs with NVUGIB are at high risk of rebleeding, and mortality is increased in AA patients. A close follow-up strategy and long-term proton pump inhibitor therapy are recommended for AA patients with peptic ulcer or esophagitis.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland.
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland.
| | - Sami Miilunpohja
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland
- Emergency Department, Kuopio University Hospital, Kuopio, Finland
| | - Tuomo Rantanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Jenni M Koskela
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Johanna Jyrkkä
- Assessment of Pharmacotherapies, Finnish Medicines Agency, Kuopio, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Hannu Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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15
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Du SS, Sun SS, Song YF, Hao SA. Efficacy of emergency endoscopy in treatment of acute non-variceal upper gastrointestinal bleeding. Shijie Huaren Xiaohua Zazhi 2015; 23:4558-4562. [DOI: 10.11569/wcjd.v23.i28.4558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical effects of emergency endoscopy in the treatment of acute non-variceal upper gastrointestinal bleeding.
METHODS: A retrospective analysis was performed of 126 patients with acute non-variceal upper gastrointestinal bleeding who were treated by emergency endoscopy or elective endoscopy at our hospital between March 2010 and September 2013. The causes of acute non-variceal upper gastrointestinal bleeding were analyzed. The rate of bleeding, the success rate of hemostasis, rebleeding rate, surgery rate and hospitalization time were compared in the two groups.
RESULTS: The most common cause of acute non-variceal upper gastrointestinal bleeding was peptic ulcer (44.4%), followed by acute gastric mucosal lesions (12.7%) and gastrointestinal cancer (11.9%). A total of 116 (126) cases of bleeding were detected, and the positive rate was 92.1%. The rate of bleeding was significantly higher in the emergency endoscopy group (97.1%) than in the elective endoscopy group (85.7%) (P < 0.05). The rebleeding rate (2.9%), surgical rate (1.5%) and hospitalization time were significantly lower in the emergency endoscopic group than in the elective endoscopy (P < 0.05).
CONCLUSION: Emergency endoscopy is convenient, efficient, and less invasive, and is the preferred treatment for acute non-variceal upper gastrointestinal bleeding.
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